What are the management and evaluation steps for a subconjunctival hemorrhage accompanied by headache?

Management and Evaluation of Subconjunctival Hemorrhage with Headache

Subconjunctival hemorrhage with headache requires urgent evaluation to rule out subarachnoid hemorrhage (SAH), especially when headache is severe and of sudden onset. This combination of symptoms warrants a thorough neurological assessment as it could represent a potentially life-threatening condition.

Initial Assessment

Headache Characteristics Requiring Urgent Evaluation

• Sudden onset, severe ("thunderclap") headache
• Described as "worst headache of life"
• Associated with nausea, vomiting, neck stiffness, photophobia
• New neurological deficits

Risk Stratification

• Apply the Ottawa SAH Rule to identify high-risk patients 1:
  • Age ≥40 years
  • Neck pain or stiffness
  • Witnessed loss of consciousness
  • Onset during exertion
  • Thunderclap headache (peak intensity within 1 hour)
  • Limited neck flexion on examination

Diagnostic Approach

For Severe, Sudden-Onset Headache with Subconjunctival Hemorrhage:

1. Immediate non-contrast head CT

   • If presenting <6 hours from symptom onset: High-quality CT interpreted by a neuroradiologist may be sufficient to rule out SAH 1
   • If presenting >6 hours from symptom onset or with neurological deficits: CT followed by lumbar puncture if CT is negative 1

2. If SAH is suspected despite negative CT:

   • Perform lumbar puncture to evaluate for xanthochromia or red blood cells 1
   • Digital subtraction angiography (DSA) is indicated if high suspicion persists 1

3. If SAH is confirmed:

   • CTA or DSA with 3D rotational angiography to identify aneurysm location 2
   • Grade severity using validated scales (Hunt and Hess, World Federation of Neurological Surgeons) 2

For Non-Severe Headache with Subconjunctival Hemorrhage:

1. Evaluate for common causes of subconjunctival hemorrhage:

   • Trauma (including minor trauma like eye rubbing)
   • Contact lens use
   • Hypertension
   • Diabetes
   • Arteriosclerosis
   • Bleeding disorders
   • Medications (anticoagulants, antiplatelets) 3

2. Physical examination:

   • Document location and extent of subconjunctival hemorrhage
   • Check blood pressure
   • Complete eye examination
   • Neurological examination

3. Laboratory testing if recurrent or extensive hemorrhage:

   • Complete blood count with platelet count
   • Coagulation profile (PT/INR, PTT)
   • Blood glucose
   • Consider testing for thrombocytopenia if extensive or recurrent 4

Management

For Confirmed SAH:

• Early aneurysm obliteration (ideally within 24 hours) 2
• Blood pressure control (systolic BP <160 mmHg) 2
• Nimodipine 60 mg orally every 4 hours for 21 days 2
• Monitor for delayed cerebral ischemia and hydrocephalus 2

For Isolated Subconjunctival Hemorrhage:

• Usually self-limiting and resolves within 1-2 weeks
• Artificial tears for comfort
• Avoid eye rubbing
• Treat underlying causes:
  • Blood pressure control if hypertensive
  • Medication adjustment if on anticoagulants
  • Proper contact lens hygiene if applicable

Special Considerations

Red Flags Requiring Further Investigation:

• Recurrent subconjunctival hemorrhages
• Bilateral extensive hemorrhages
• Associated bleeding from other sites
• History of bleeding disorders
• Unexplained headaches

Follow-up:

• Isolated subconjunctival hemorrhage: Reassurance and follow-up in 2 weeks if not resolved
• If associated with SAH: Follow neurosurgical protocols for monitoring and management

Pitfalls to Avoid

• Don't dismiss the combination of subconjunctival hemorrhage and severe headache as unrelated events, especially with thunderclap headache
• Don't miss sentinel headaches which occur in 10-43% of patients before major aneurysmal SAH 2
• Don't rely solely on negative CT if clinical suspicion for SAH is high, especially if >6 hours from symptom onset 1
• Don't forget to check for systemic causes in recurrent or extensive subconjunctival hemorrhage 3

Remember that misdiagnosis of aneurysmal SAH is associated with a nearly 4-fold higher likelihood of death or disability at 1 year 2. When in doubt, pursue more aggressive evaluation.